2020 CSM Abstracts
Thursday
Interrater Reliability of a Novel Treatment Fidelity Tool Examining Guideline Adherence of Physical Therapists
Alexandra Zigmont, Brian Feng, Thomas R. Denninger, Adam Daniel Lutz, Ellen Shanley, Michael Kissenberth, Charles Alden Thigpen
PURPOSE/HYPOTHESIS: Fidelity to guideline care recommendations is thought to decrease unwanted variability in care and optimize physical therapy outcomes. Having a standardized measure to evaluate the delivery of physical therapy services is key as value-based reimbursement models become standard. This fidelity tool was designed to examine utilization of guideline adherent care as it is reflected in current best practice recommendations. The purpose of this study was to examine interrater reliability of the fidelity tool between 2 clinician-examiners across a random sample of 25 patients enrolled in an optimized PTfirst program.
NUMBER OF SUBJECTS: Charts review of a random sample of 25 patients enrolled in an optimized PT-first program.
MATERIALS AND METHODS: Two independent clinician-examiners were trained in the administration of a 10-item fidelity tool. Each of the 10 items was scored “yes” or “no” based upon adherence to a component of the guideline based care model based off of patient initial presenting irritability; a composite score summed all “yes” responses for a maximum possible score of 10. Interrater reliability was calculated for each item using an unweighted kappa statistic; while a weighted kappa statistic was used to assess interrater reliability for the composite score. Strength of agreement was classified using the initial cut points recommended by Cohen.
RESULTS: Of the 10 items, a kappa statistic could not be calculated for the item evaluating the review of patient goals due to uniform responses by 1 reviewer. Of the remaining 9 items, 2 were deemed to have poor agreement (review of prognosis, κ = –0.19); appropriate manual therapy for reported irritability (κ = –0.10), 3 demonstrated fair agreement (appropriate strengthening for reported irritability (κ = 0.20); appropriate modalities for reported irritability (κ = 0.26); treatment time 60 to 75 min per session (κ = 0.28), 2 demonstrated moderate agreement (appropriate scheduling at initial evaluation (κ = 0.41); appropriate actual visits attended (κ = 0.51), 1 demonstrated substantial agreement (diagnosis matches documented patient presentation (κ = 0.65), and 1 demonstrated almost perfect agreement (appropriate mobility exercises for reported irritability (κ = 0.82). The composite score demonstrated moderate agreement (κ = 0.48).
CONCLUSIONS: Analysis of appropriate treatment patterns that is adherent to best practice recommendations is crucial to translational research that reviews more detail than financial coding. Overall the tool suggests moderate interrater reliability between 2 clinician-examiners. Out of 9 items available for calculation, 4 items were found with either moderate or better agreement and 5 were found with fair or worse agreement. This preliminary evaluation provides important information to refine the tool and training to ensure consistent interpretation of items in the tool.
CLINICAL RELEVANCE: With further refinement and testing, the fidelity tool may prove useful in determining adherence to evidence-based care guidelines for physical therapists.
Evaluation of Guideline Adherent Education for Therapists Seeing Patients in an Optimized Early PT Pathway
Hank Havlin, Thomas R. Denninger, Adam Daniel Lutz, Ellen Shanley, Michael Kissenberth, Charles Alden Thigpen
PURPOSE/HYPOTHESIS: Guideline adherence is thought to decrease variation in care and in turn deliver improved patient outcomes at a lower cost. However, it is unclear how to disseminate and implement guideline care into practice. Therefore, the purpose of this study is evaluate therapists guideline fidelity relative to the program tenets of guideline care in the preprogram workshop.
NUMBER OF SUBJECTS: One hundred twenty charts of patients with back (n = 34), neck (n = 24), knee (n = 30), and shoulder (n = 32) complaints treated by therapists (n = 99) who underwent training in guideline adherent care pathways.
MATERIALS AND METHODS: Physical therapists (n = 99) completed a standardized 6-hour training across MSK conditions in a staged algorithm for diagnosis and treatment classification. A random sample of their patients (n = 120) were selected from all patients (n = 592) that participated in a targeted “early physical therapy” program for MSK conditions in 2018. A tool to assess fidelity of symptom irritability and treatment delivered was utilized to assess compliance to training during manual chart review. Each of the 10 items was scored “yes” or “no” based upon adherence to a component of the guideline-based care model based off of patient initial presenting diagnosis, irritability and treatment delivered. Additionally, a composite score summed all yes responses for a maximum possible score of 10. High, moderate, and low fidelity was determined based on cut scores associated with achieving clinically important improvements in patient reported outcomes in a prior study.
RESULTS: Therapists displayed high (18.3%), moderate (66.7%), and low fidelity (15%) fidelity across all body regions. Shoulder (44.4%) and back (33.3%) comprised the majority of low fidelity patient cases across the sample. As the intent of training was to minimize low fidelity treatment, considered to consistent of treatment that was least guideline care. Shoulder cases demonstrated the highest rate of low fidelity treatment, with 25% of patients receiving low fidelity care. Patients with back pain received low fidelity care 17.6% of the time. Knee (10%) and neck (4.2%) received low value care significantly less frequently.
CONCLUSIONS: Our results show lower treatment fidelity for back and shoulder conditions compared to neck and knee. This suggests improvements in educational approach is needed including review the training content, post course follow, and pre-education measures. Future study is required to deliver a sustainable program that decreases unwanted variation in care.
CLINICAL RELEVANCE: There was significant variability in observed levels of treatment fidelity post training across body regions.
Friday
A Comparison of Concussions and MSK Injuries in Middle and High School Student-Athletes.
Sarah Peterson, Adam Daniel Lutz, Charles Alden Thigpen, Ellen Shanley
PURPOSE/HYPOTHESIS: Concussions and serious musculoskeletal (MSK) injuries in middle (MS) and high (HS) school athletes are a major concern due to negative academic and social ramifications. Few studies have examined the incidence and risk differences of concussions and MSK injuries between HS and MS student-athletes. Therefore, the purpose of this study was to report cumulative incidence and identify absolute risk differences in concussions and MSK injuries.
NUMBER OF SUBJECTS: One thousand fifty MS and 6968 HS student-athletes followed for 2017-2018 sport seasons.
MATERIALS AND METHODS: Total sport participation and injuries were documented by Athletic Trainers (AT) for MS and HS student-athletes from a large Athletic Repository. Cumulative incidence of concussions and MSK injuries are reported per 100 student-athletes with 95% confidence intervals (CI). Separate chi-square tests examined differences between MS and HS student-athletes by contact status (contact or non) and severity based on time loss (severe, >21 days; mild/moderate, 7-21 days).
RESULTS: There were 311 (MS) and 1577 (HS) total injuries yielding cumulative incidence values of 29.6 and 22.6 per 100 athletes, respectively. MS student-athletes displayed an absolute risk difference of 6.9% (95% CI: 4.1%, 9.9%) greater than HS student athletes. HS athletes were 1.1 (95% CI: 1.0, 1.2; P = .047) times more likely to suffer a contact injury compared to MS athletes. MS athletes suffered concussions at a greater rate 5.4 and 3.0 per 100 athletes compared to HS athlete yielding an absolute risk difference of 2.4% (95% CI: 1.2%, 4.0%). Relative risk for mild or moderate (7-21-day time-loss injury) and severe/season ending (>21- day time-loss injury) was not different between MS and HS student athletes (P = .2).
CONCLUSIONS: Our results show MS athletes were at higher risk for concussion and MSK injury compared HS student-athletes. Future studies are warranted to confirm and explore these results.
CLINICAL RELEVANCE: Adolescent athletic injuries are common and MS athletes experience injuries similar to older HS athletes. Athletic medical coverage and support for athletic injuries should consider providing similar attention to MS as HS sports.
RTS Prior to 7 Months Post Aclr Is Associated with Decreased Future Participation
Deidra Ellen Debnam, Charles Alden Thigpen, Courtney Ross Chaaban, Jason Folk, Michael Kissenberth, Douglas Wyland, Ellen Shanley
PURPOSE/HYPOTHESIS: Approximately 50000 ACL injuries occur in US high school athletes each year. Previous research indicates varied rates of return to sport across all ACL injuries, and time to return to sport has been identified as important with respect to risk of future injury. However, few studies have examined these variables in high school athletes.
NUMBER OF SUBJECTS: Eighty-six (34 female) scholastic athletes (mean ± SD age, 15.9 ± 1.6 years) participated in the study.
MATERIALS AND METHODS: ACL injured athletes were identified by the school athletic trainer (AT) who confirmed they sustained their injury during a scholastic team-sponsored practice or game. Each athlete underwent ACL reconstruction, reported intention to return to sport of injury, and completed a criterion-based physical therapy program. ATs documented physician clearance and return to sport during the following academic season. ATs also documented participation, injury occurrence, and time loss for all athletes. Athletes were identified as able to return to sport if they were fully participating for the complete season in their sport of injury without time loss due to injury. A chi-square test was used to determine the difference in injury frequency between those athletes returning to sport before versus after 7 months from the date of surgery. Relative risk ratios were calculated comparing the risk of reinjury for athletes who returned to sport earlier than 7 months compared to those who did not. Statistical significance was set a priori at α = .05.
RESULTS: Of 86 high school athletes, 65 (75%) were able to return to their sport of injury the following scholastic season while 21 were not. Athletes returned to sport on average 7.5 months following surgery (range, 5-14 months). When evaluating time to return to sport, athletes who returned to sport at less than 7 months (9 athletes) following surgery were 17 times (95% CI: 3.1, 111.0) more likely to fail to return for a full season compared to athletes who returned after 7 months (38 athletes). Of the athletes able to return to sport, 20/65 (30%) experienced subsequent injuries, with 10 of those injuries resulting in time loss, none of which were ACL injuries. This means that 57 (88%) were able to play the entire season without time loss. Time loss injuries were not influenced by time to return to sport (P>.05).
CONCLUSIONS: High school athletes increase their risk of failure to complete their next scholastic sport season following ACLR when they return to sport before 7 months post surgery. Only half of the athletes who returned to their sport of injury prior to 7 months were able to complete that season without a time-loss injury.
CLINICAL RELEVANCE: This study is novel in its ability to evaluate ACL injury and return to sport in a high school population, with injury, participation, and subsequent injury documented at scholastic events. While 74% of our high school athletes returned to sport, not all completed the next season. Our results are consistent with other populations showing that delaying return to full participation until at least 7 months should be strongly considered following ACLR.
Does Mechanism of Injury Influence Patient Outcomes (PROs) and Treatment Metrics in Shoulder Instability Patients?
Carlos Gonzalez, Adam Daniel Lutz, Caitlin Ludington, Logan John Gudde, Ellen Shanley
PURPOSE/HYPOTHESIS: Previous research indicates that physical therapy is an appropriate intervention for shoulder instability based on post-intervention PROs. However, no study has examined differences in PROs and episode-level treatment metrics by mechanism of injury (MOI; sport or non-sport). The purpose of this study was to examine differences in PROs and episode-level treatment metrics by MOI
NUMBER OF SUBJECTS: 51 patients with shoulder instability (MOI sport n=21, other n=30)
MATERIALS AND METHODS: Demographic information and episode-level treatment metrics (CPT codes, visits, and PROs) were extracted from the ATI Patient Outcomes Registry. Additional chart review was completed to confirm diagnosis of shoulder instability, MOI, and baseline irritability. Patients were excluded if the episode of conservative care was less than 2 weeks or if pertinent baseline or episode-level information were unavailable. Separate univariate ANOVAs compared differences between groups for initial and final PENN scores, and episode level treatment parameters(active, exercise-based units per visit (UPV), manual therapy (MT) UPV, and modality (mod) UPV). Statistical significance was established a priori (α=0.05).
RESULTS: Shoulder instability with sport MOI demonstrated higher initial PENN compared to other MOI (66.9±20.4 vs 51.7±21.6;p=0.02), respectively. The same was true of final PENN (88.1±15.6 vs 77.5±20.3;p=0.05). There was no significant difference in change in PENN (p=0.488). Episode-level treatment metrics including active physical therapy utilization demonstrated similar active UPV (3.3±0.6 vs 3.1±0.6;p=0.1866), MT UPV (0.5±0.5 vs 0.8±0.6;p=0.098), mod UPV (0.2±0.5 vs 0.3±0.4;p=0.3678), and visits (12.8±5.3vs 15.6±8.3;p=0.169)
CONCLUSIONS: This study demonstrates that patients with sports-related shoulder instability display greater self-reported function at baseline and discharge despite similar intensity and duration of physical therapy treatment than those presenting with other mechanisms of injury. Additional studies will be needed to confirm these results in larger cohorts of shoulder instability patients
CLINICAL RELEVANCE: Patients with a sport related MOI achieved higher outcome scores at the completion of rehabilitation when compared with patients with non-sport related injury
mechanisms. This may indicate that an overall return to higher functional is possible. However, additional studies in this patient population with larger cohorts and longer follow up will be
needed to confirm these results.
Comparing Short Term Outcomes for Acute and Chronic Shoulder Instability with Conservative Treatment. Abstract Accepted for Poster Presentation
Caitlin Ludington, Adam Daniel Lutz, Logan John Gudde, Carlos Gonzalez, Ellen Shanley
PURPOSE/HYPOTHESIS: Effective non-operative management of shoulder instability typically incorporates specific exercise programs targeting scapular and glenohumeral stabilization, and neuromuscular control into a comprehensive treatment plan. No prior studies have examined differences in treatment characteristics or patient reported outcomes between patients treated conservatively for acute and chronic shoulder instability. The purpose of this study was to compare treatment characteristics and short-term Penn Shoulder Scores (PENN) between patients treated conservatively for acute and chronic shoulder instability
NUMBER OF SUBJECTS: 34 patients diagnosed with acute (n=18) or chronic instability (n=16)
MATERIALS AND METHODS: Patients that completed a course of physical therapy at ATI Physical Therapy in Washington state with a primary diagnosis of shoulder instability, confirmed by chart review, were considered for inclusion. Postoperative patients and those with concomitant fracture were excluded. Baseline patient information and episodic treatment characteristics were extracted from the ATI Patient Outcomes Registry. Separate univariate ANOVA’s were used to compare differences in treatment metrics, visits, and short-term PENN between
patients with acute and chronic instability. Significance was set a priori at P<0.05
RESULTS: There were no significant differences between patients with acute and chronic shoulder instability for age, BMI, number of visits or units per visit completed; females were
more likely to have chronic shoulder instability (p=0.04) and those with a history of dislocation were equally likely to have acute or chronic instability (p=0.2). Those being treated for acute
instability had higher final PENN scores (91.5 ± 9.2 vs.78.6 ± 20.0; P=0.02) and greater change in PENN scores (35.6 ± 17.5 vs 11.9 ± 19.0; P<0.001). While not significant, initial PENN scores trended towards being higher in those with chronic instability
CONCLUSIONS: This study demonstrates significantly better short-term outcomes for patients presenting with acute versus chronic shoulder instability. In patients with chronic shoulder instability, conservative treatment seems to improve function in the short term, but the improvement remains below the MDC, and just above the MCID for the PENN. These findings suggest that efforts to restore short term function and preventing should focus on identifying patients suffering acute shoulder instability to maximize function
CLINICAL RELEVANCE: This study demonstrates good utility of conservative treatment for acute shoulder instability in the short term. Further research comparing long term outcomes, as well as other treatment options for chronic instability may be warranted.
Are Patient Outcomes (PROs) and Treatment Metrics Different Based on Irritability in Shoulder Instability Patients?
Logan John Gudde, Ellen Shanley, Carlos Gonzalez, Caitlin Ludington, Adam Daniel Lutz
PURPOSE/HYPOTHESIS: Previous research has compared PROs after surgical versus conservative, non-operative treatment for shoulder instability. Additionally, studies have highlighted effective rehabilitation programs for patients with shoulder instability managed conservatively. However, no research to this date has examined differences in follow-up PROs and episode-level treatment metrics between levels of baseline irritability for patients with shoulder instability treated conservatively. The purpose of this study was to examine differences in follow-up PROs and episode-level treatment metrics between levels of baseline irritability for patients with shoulder instability treated conservatively.
NUMBER OF SUBJECTS: 52 patients treated non-operatively for shoulder instability. Patients were included in the study if they had a primary complaint of shoulder instability and excluded if they presented with previous shoulder or cervical surgery, or neurological involvement
MATERIALS AND METHODS: Demographic information and episode-level treatment metrics (CPT codes, visits, and PROs) were extracted from the ATI registry. Patients were classified at baseline with low, moderate, or high irritability using published criteria. The primary PRO used in this study was the Penn Shoulder Score (Penn). Additional episode-level treatment metrics
calculated for each group were number of visits, units, and skilled (active + manual). Statistical analysis was conducted using a one-way ANOVA with Tukey post-hoc testing (α=0.05).
RESULTS: There was a significant difference between each of the 3 irritability groups for initial Penn score: low (74.2±15.7), moderate (59.8±13.3), high (35.8±14.5). The high irritability group (71.4±21.0) had a significantly worse final Penn score compared to the low (86.4±18.2, p=0.03) and moderate (87.3±11.7, p=0.05) irritability groups; no difference existed between the moderate and low irritability groups. The high irritability group had significantly more visits (18.5±10.5 vs 12.4±4.3, p=0.02), total units billed (83.2±56.4 vs. 52.4±21 p=0.03), and skilled units billed (72.8±45.4 vs. 47.6±17.6, p=0.03) when compared to the low irritability group; no other differences were identified
CONCLUSIONS: When comparing each level of irritability, the high irritability group reported significantly worse final Penn Shoulder Scores than the other two groups and required more physical therapy visits and billed units. The low and moderate irritability groups appear to be similar in outcomes and fidelity metrics
CLINICAL RELEVANCE: This study demonstrates that highly irritable patients with shoulder instability may require increased treatment intensity and resources when treated conservatively. Future research should focus on treatment strategies to improve outcomes for these patients.
Utility of the Single Alpha Numeric -Evaluation (SANE) in Rehab Phases of Baseball
Wesley Edward Talley, Charles Alden Thigpen, Daniel Kline, Michael Kissenberth
PURPOSE/HYPOTHESIS: Region and activity specific patient-reported outcomes (PROs) have been used to examine function following treatment in patients and athletes. Previous studies have examined region specific PROs to help guide care through the rehab process and activity related PROs to clarify function at time of return to sport. The reliability and validity of the SANE has been established in those with knee and upper extremity impairments. The validation of the Functional Arm Scale for Throwers (FAST) has been established as a possible region (shoulder and elbow) and activity related PRO for softball and baseball players helping to guide care players through rehab and back to sport.
NUMBER OF SUBJECTS: Thirty-one baseball players were referred to physical therapy for the management of either elbow or shoulder pathology related to sport.
MATERIALS AND METHODS: Demographics including age, height/weight, school year, position, and hand dominance were collected to determine if associations exist between position, rehabilitation phase, body segment, and injury recovery. Starters and relief pitchers were grouped as pitchers while any player primarily acting as an infielder, outfielder, or catcher was grouped as a position player. FAST and SANE were given throughout the rehab process to determine if an association existed between the SANE and the FAST. The SANE is a 1 question survey that asks patients to rate the percentage of normal for their shoulder/elbow. The FAST is a 22-question survey with an additional 9 questions for pitchers. The questions are phrased in a way that asks about the ability to complete daily activities, to throw and to function in sport. Bivariate correlations and univariate ANOVAs were used to determine the association and between group differences of the PRO, player position, phase of rehabilitation and injury site.
RESULTS: There were 17 elbow and 14 shoulder patients presenting for rehabilitation (average age, 16.3 years). There was a similar number of conservatively treated elbow and shoulder patients (P = .63). The FAST and SANE scores were similar for players regardless of position. Outcome measures were highly correlated for both pitchers (r = 0.92) and position players (r = 0.77). The FAST and SANE are correlated at r = 0.82 (P = .001) and r = 0.8 (P = .001) in initial and return to throwing phases respectively. The scores differed for players based on the phase of rehab and position (46.1 ± 25.2 versus 22.00 ± 17) as well as during the initial and return to throwing phases in pitchers and (53 ± 10.5 versus 28 ± 13.1) in position players. Scores demonstrate significantly less disability in the interval throwing phase (P = .001).
CONCLUSIONS: Based on these results, there is a high correlation between the SANE and the FAST regardless of position played. The SANE can be used to measure progress for athletes with either shoulder or elbow impairments and guide care through the phases of rehab.
CLINICAL RELEVANCE: This study demonstrates that the SANE can be used to measure progress through rehab for baseball players
LE Injury Is Not Associated with Concussions in Football Players Regardless of Heads up Training
Abigail Pinkerton, Ellen Shanley, Charles Alden Thigpen, Gil Gilliland, John Thorpe, Michael Kissenberth
PURPOSE/HYPOTHESIS: An estimated 1.6 to 3.8 million sports-related concussions (SRC) occur in the US annually. Troubling is that following SRC, athletes have 2.5 times greater odds of sustaining a lower extremity musculoskeletal (LE MSK) injury compared to athletes without concussion. While educational and prevention programs like US football heads-up (HU) educational program training in high school football has shown the ability to significantly lower concussion rate compared with players without HU training, it is unknown the influence on LE MSK injury. Therefore, the purpose of this study was to compare SRC and LE MSK injury rates in a group of high school athletes with and without HU training (NHU).
NUMBER OF SUBJECTS: A total of 2514 high school football players were monitored throughout their competitive season.
MATERIALS AND METHODS: Fourteen high schools (1818 athletes) who received US football HU training were compared to 10 high schools (696 athletes) who did not. At all schools, SRC and LE MSK injury time-loss injuries were documented by the athletic trainer. LE MSK injuries were included if they occurred within 60 days before or following the SRC. Cumulative incidence and incidence rate ratios (RR) were calculated for both groups with 95% confidence intervals (CI).
RESULTS: A total of 117 SRC (HU, 75; NHU, 42) and 393 LE MSK injuries (HU, 295; NHU, 98) were observed. The HU trained group had significantly lower concussion rate (4.1 versus 6.0 per 100 athletes) compared to NHU group (RR = 1.5; 95% CI: 1.1, 5.4). There was no significant difference in the incidence of LE MSK injury between the HU trained group (16.2 versus 14.1 per 100 athletes) and the NHU group (RR = 0.87; 95% CI: 0.7, 1.1). A total of 19 athletes sustained a LE MSK injury and SRC during season. There was no significant difference in the incidence of combined injury between the HU trained group (0.72 versus 0.86 per 100 athletes) and the NHU group (RR = 1.2; 95% CI: 0.46, 3.2).
CONCLUSIONS: Our results show that HU training is an effective in reducing the concussion rate in high school football athletes. In contrast to other reports we did not observe any association between concussion and LE MSK injury in our study or influence LE MSK injury rate. Future work is required to understand the association between initial injury recovery and subsequent injury risk.
CLINICAL RELEVANCE: Educational programs like heads up training appear to be an effective concussion injury reduction strategy without any adverse effects on LE MSK injuries and should be considered in high risk concussion sports.
Physical Therapy Management of Shoulder Pain and Dysfunction Following Carotid Endarterectomy: A Case Report
Joshua Holskey, Neha Chowdhary, Thomas Denninger
BACKGROUND AND PURPOSE: Spinal accessory nerve palsy is a rare complication of carotid endarterectomy (CE). Patients typically describe delayed-onset shoulder pain and dysfunction secondary to loss of upper trapezius function on scapulohumeral rhythm. Physical therapy (PT) management of shoulder dysfunction is often recommended, however only one previous case has been described after CE. The purpose of this case report is to describe the differential diagnosis and PT management of a patient with shoulder pain and dysfunction secondary to spinal accessory nerve palsy after CE
CASE DESCRIPTION: The patient was a 74 year-old male who presented to PT 6 weeks after CE for accessory nerve palsy. He complained of severe shoulder pain and loss of right arm function. At PT evaluation, the patient presented similar to a massive rotator cuff tear. Forward elevation AROM was limited to 93° with a classic scapular elevation compensatory pattern. Scapular winging was also noted, and the patient was unable to maintain prone horizontal abduction when passively placed into the position. His condition was rated as high severity and irritability, so initial intervention focused on manual therapy applied to the cervicothoracic spine along with gentle PROM. As irritability decreased, PROM was progressed towards end range and active range of motion progression was initiated. This was done in a gravity-modified manner beginning in supine, transitioning to side-lying, and then eventually a lawn chair progression towards standing. Strengthening prescription and progression was then initiated similar to typical rehab after rotator cuff repair. During the course of rehab, the patient developed notable atrophy of the upper trapezius. Electrodiagnostic testing confirmed a right-sided spinal accessory neuropathy with axonal features. The patient was progressed through rehab as noted until he had reached maximum function and demonstrated independence with HEP for continued strengthening.
OUTCOMES: The patient attended 32 PT visits over a 6-month period. His pain decreased from 8/10 at initial evaluation to 0/10 at discharge. Right shoulder AROM improved from 93° to 122°. Strength was not assessed at initial evaluation due to high irritability and lack of full AROM. At discharge, the patient had 75% scaption strength, 65% ER, and 99% IR as compared to his uninvolved side as measured by hand held dynamometry. These noted improvements in impairments from his initial evaluation contributed to an improvement on the Quick DASH from a worst of 41% disability to 2% at discharge
DISCUSSION: Physical therapy intervention can be successful in treating shoulder pain and dysfunction secondary to spinal accessory nerve palsy. While rare, this is a possible sequela of carotid endarterectomy, and physical therapists should consider this as a possible differential diagnosis in patients post CE. This case report updates the treatment of this condition from a previous case report using the Maitland concept as a guide for initial management. Once symptoms were stable, typical rotator cuff rehab allowed this patient to return to excellent function of his right upper extremity.
Time to ACL Reconstruction Influences Return to Sport the Following Season
Brittany Britt, Ellen Shanley, Courtney Ross Chaaban, Sarah Babrowicz, Michael Kissenberth, Douglas Wyland, Charles Alden Thigpen
PURPOSE/HYPOTHESIS: Approximately 50,000 ACL injuries occur in US high school athletes each year. Previous research indicates varied rates of return to sport across all ACL injuries, and treatment type and timing. However, few studies have examined these variables in high school athletes. The purpose of this study is to determine if time to surgery and number of physical therapy visits impact the athlete’s ability to return to sports
NUMBER OF SUBJECTS: 79 (30F, 49M) high school athletes (avg. 15.9 yo±1.6) participated in the study
MATERIALS AND METHODS: ACL injured athletes were identified by their school athletic trainer (AT) who confirmed they sustained their injury during a scholastic team-sponsored practice or
game. Each athlete underwent ACL reconstruction and reported intention to return to sport at the time of surgery. ATs documented the date, mechanism, and sport of injury. Orthopedic
surgeons reported the type of surgery, graft type, date of surgery and clearance to return to sport. Patients participated in a standardized physical therapy program including a return to
sport battery. Chi square analyses and univariate ANOVAs were used to compare ability to RTS (yes or no) based on gender, graft type, delay to surgery and average physical therapy visits (α=0.05)
RESULTS: Of 79 scholastic athletes, 62 (75%) were cleared to return to their sport(9.0 ±2.5 months) the following season while 17 did not return. Of the athletes, unable to return to sport,
a significantly longer average time to surgery was noted (97 vs 47 days, P=0.005). Athletes unable to RTS performed significantly fewer SLRs at 12 weeks(21±12). There was no
difference in gender (P=0.17), graft type (P=0.7), or PT visits(P=0.4) when comparing those cleared versus those unable to RTS
CONCLUSIONS: Athletes who had earlier surgical reconstruction of their ACL were more likely to return to sport the following season
CLINICAL RELEVANCE: This study is novel in its ability to evaluate ACL the ability to return to sport in a scholastic population, based on gender, graft type, number of PT visits and delay in
surgical stabilization
Saturday
Criterion Validity, MCID and SCB Calculation of the MDQ and SANE for Patients with LBP
Adam Daniel Lutz, Thomas R. Denninger, Ellen Shanley, Brett Windsor, Charles Alden Thigpen
PURPOSE/HYPOTHESIS: The collection of patient reported outcomes (PROs) is increasingly important as the physical therapy profession moves toward value-based reimbursement. Efficient and appropriate collection of PROs is in the best interest of both physical therapists and patients. The Single Assessment Numeric Evaluation (SANE) is a single-item survey that asks a patient “What percentage of normal is your (body region of interest)?” and has been validated across several body regions. The Modified Low Back Pain Disability Questionnaire (MDQ) is the most commonly used PRO for patients with low back pain (LBP) but only 1 study has examined its psychometric properties. The purpose of this study was to test criterion validity of the SANE relative to the MDQ and determine an anchor-based minimal clinically important difference (MCID) and substantial clinical benefit (SCB) using the global rating of change (GRoC) for each questionnaire for patients with LBP.
NUMBER OF SUBJECTS: Two hundred six patients seeking physical therapy for LBP through employer-based “early physical therapy” program that met inclusion criteria described below.
MATERIALS AND METHODS: Patient data, including MDQ, SANE, and GRoC, were obtained for a convenience sample of patients seeking care in upstate South Carolina between 2016 and 2018. Patients were considered only if pre/post PROs were present for each (MDQ, SANE) and followup PROs (MDQ, SANE, GRoC) were obtained between 2 and 12 weeks of initial PRO. Patients with surgery or injection in the 90 days prior to initial evaluation were excluded. Criterion validity was established using Pearson’s correlation for all matching observations of MDQ and SANE (including initial and follow-up observations). Anchor-based MCID and SCB measures were calculated using a ROC curve for each PRO (MDQ, SANE). “Success” for MCID included all patients reporting that symptoms were “moderately improved” or better; while “success” for SCB included only patients reporting that their symptoms were “a great deal better.”
RESULTS: The final analytical sample included 206 patients (412 total matching MDQ, SANE outcomes). Pearson correlation across all matched observations was –0.567 (P<.001) indicating moderate correlation. Values of 11.2 and 14.2 were calculated for MCID (n = 157, 76.2%) and SCB (n = 103, 50%) for the MDQ; while like values of 17.0 and 23.9 were identified for the SANE.
CONCLUSIONS: The SANE is moderately correlated with MDQ and therefore demonstrates criterion validity for evaluation of symptoms in patients with LBP. Accordingly, it may be a useful, efficient tool to use for intermediate PRO collection in these patients, providing valuable information on status change that might warrant administration of the more comprehensive MDQ. This study also offers a follow-up MCID calculation for MDQ and introduces calculations of MCID for the SANE and SCB for both SANE and MDQ for patients with LBP.
CLINICAL RELEVANCE: Understanding MCID and SCB values for the MDQ and SANE can inform treatment progression and whether appropriate to complete more comprehensive re-evaluation
Athlete’s Diagnosed with Anterior and Posterior Shoulder Instability Display Different Chief Complaints and Disability
Ellen Shanley, Adam Daniel Lutz, Jared Hudspeth, Kyle Adams, Charles Alden Thigpen, John M. Tokish, Amit Moyama, Michael Kissenberth
PURPOSE/HYPOTHESIS: Anterior shoulder instability is a common complaint of young athletes. Posterior instability in this population is less well understood and the standard of care has not been defined. The purpose of the study was to compare index frequency, treatment choice, and athlete disability following an incident of anterior or posterior shoulder instability in high school and collegiate athletes.
NUMBER OF SUBJECTS: Fifty-nine high school and collegiate athletes (n = 30 athletes with anterior instability, n = 29 athletes with posterior instability) were included.
MATERIALS AND METHODS: Athletes suffering from a traumatic sport related shoulder instability episode during a team-sponsored practice or game were identified by their school athletic trainer (AT). Athletes were referred to the sports medicine physician or orthopaedic surgeon for diagnosis and initial treatment choice (operative versus nonoperative). Athlete’s diagnosed with traumatic anterior or posterior instability that completed a full course of medical and rehabilitation treatment including pre and patient reported outcomes were included in the study. The frequency of shoulder instability was compared by direction, mechanism of injury (MOI) and treatment choice through chi square analyses and a repeatedmeasures analysis of variance was used to compare the functional outcomes by treatment type and direction of instability (α = .05).
RESULTS: Athletes diagnosed with anterior instability were more likely to report a chief complaint of instability (70%), while those diagnosed with posterior instability reported a primary complaint of pain (96%) interfering with function (P = .001). The primary MOI (contact versus noncontact) and initial treatment choice for those sustaining anterior instability was similar to those with posterior instability (MOI, 77% versus 54%; P = .06; surgical treatment, 60% versus 72%; P = .31). When considering patient function, pre- and post-treatment Penn Scores were similar for all athletes diagnosed with instability whose initial course of treatment was operative (P>.05). In patients with a nonoperative course of care those diagnosed with anterior instability were initially significantly more disabled than those with posterior instability (32 ± 6.1 versus 58 ± 8.1, P = .001). There were no differences in functional outcomes at discharge in those treated nonoperatively regardless of direction of instability (P = .24); however, change in Penn was significantly greater in those with anterior (61 ± 18.7) than those with posterior (27 ± 25.2) instability (P = .002).
CONCLUSIONS: Athletes with anterior instability appear to have different mechanisms and complaints than those with posterior instability. Among those that receive nonoperative treatment, athletes with anterior instability have significantly greater initial disability and change in disability than those with posterior disability during course of care. Future study is warranted to verify these results.
Evaluation of Symptom Irritability Treatment Classification for MSK Conditions
Orion Kooistra, Andrew Adam, Thomas R. Denninger, Adam Daniel Lutz, Ellen Shanley, Michael Kissenberth, Charles Alden Thigpen
PURPOSE/HYPOTHESIS: Symptom irritability treatment classification has been proposed as a component to guide treatment and decrease unwanted variation in care of musculoskeletal conditions. The staged treatment approach proposes using broad pathoanatomic categories, then symptom irritability to guide clinical decisions in the rehabilitation of musculoskeletal (MSK) conditions. Few studies have evaluated this proposed clinical approach. The purpose of this study was to examine the relationship between patient reported outcomes (PROs) and the physical therapist assigned symptom irritability treatment classification to the patient at initial evaluation
NUMBER OF SUBJECTS: 94 patients (age 47.5±12.4; female n=75) with back (n=29), neck (n=24), knee (n=15), and
shoulder (n=26) pain presenting to physical therapy
MATERIALS AND METHODS: Physical therapists (n=99) completed a standardized 6-hour training across MSK conditions in a staged algorithm for diagnosis and treatment classification. A random sample of their patients (n=94) were selected from all patients (n=592) that participated in a targeted ‘early physical therapy’ program for MSK conditions in 2018. Patients treated for MSK complaints completed an appropriate baseline body region-specific PRO at their initial evaluation; all PROs were standardized to a 0 (high disability) to 100 (no disability) scale. A one-way analysis of variance (ANOVA) was used to compare initial standardized PRO values between irritability classifications (α=0.05) for each body region then collapsed across all body regions. Tukey’s post-hoc tests was used to identify where significant between group differences
RESULTS: Evaluating physical therapists classified patients as high (n=16), moderate (n=44), and low (n=34) irritability across all MSK conditions. There were not any differences in average PRO scores for between body regions by irritability level therefore only the collapsed, standardized PRO values are provided. There was a significant difference in initial PROs for patients classified as high (mean 43±17.6), moderate (58±13.7) and low (77±13.5) irritability (P<0.001). Post hoc tests showed significant differences between high and moderate (15; 95% confidence interval 5.2,25.2), high and low (34; 23.5,44.2), and moderate and low (15; 10.8,26.5), respectively
CONCLUSIONS: Clinically important differences in baseline PRO were identified between physical therapist symptom irritability treatment classification levels. This suggests that symptom irritability classification differentiates patients based on their baseline disability and may be used to inform initial treatment strategies. Future studies should evaluate if this approach decreases unwanted variability in conservative management of MSK disorders
CLINICAL RELEVANCE: Physical therapists trained in a symptom irritability treatment classification as a part of a staged treatment strategy appear to accurately classify patient irritability level relative to initial PRO. This accurate classification allows for appropriate clinical reasoning by the physical therapist and provides the framework to decrease unwanted variation in care patterns
Guideline Adherence Associated with Better PROs in Patients with High Irritability
William Jackson, Samuel J. Recinos, Thomas R. Denninger, Adam Daniel Lutz, Ellen Shanley, Michael Kissenberth, Charles Alden Thigpen
PURPOSE/HYPOTHESIS: Matched selection and timing of interventions is thought to be important based on patient factors such as diagnosis and symptom irritability. However, there is limited evidence that classification based on symptom irritability is a valuable adjunct to selection of treatments. Therefore, the purpose of this study was to determine if adherence to training for initial management strategies based on symptom irritability influenced patient outcomes. We hypothesized that higher fidelity will lead to superior outcomes in all irritability groups
NUMBER OF SUBJECTS: 94 patients with back (n=29), neck (n=24), shoulder (n=26), or knee (n=15) pain treated by physical therapists in a targeted ‘early physical therapy’ program
MATERIALS AND METHODS: Physical therapists (n=99) completed a standardized 6-hour training across musculoskeletal (MSK) conditions in a staged algorithm for diagnosis and treatment classification. A random sample of their patients (n=94) were selected from all participants (n=592) of a targeted ‘early physical therapy’ program for MSK conditions in 2018. Patients treated for MSK complaints completed appropriate baseline and discharge body region-specific PROs; PROs were standardized to a 0 (high disability) to 100 (no disability) scale aggregated
to a single outcome for this study. Therapists classified each patient at initial evaluation to ‘high’, ‘moderate’ or ‘low’ symptom irritability level based on pain, disability levels, and symptom
state. Chart reviews were used to assess adherence to training—including appropriate matching of symptom irritability and care delivery. A mixed-model analysis of variance
(symptom irritability X treatment fidelity) was used to compare the aggregated standardized change in PRO (pre to post treatment; α=0.05). Tukey’s post-hoc tests was used to identify
where significant between group differences occurred
RESULTS: Patients were classified as having high (n=16), moderate (n=44), and low (n=34) baseline symptom irritability, and separately as having high (n=20), moderate (n=50) or low
(n=24) treatment fidelity across MSK conditions. Patients with high irritability and fidelity averaged significantly greater PRO change (12.3 ±6.5) than those with high irritability and low
fidelity (-5.6±8.362) with a mean difference in final outcome of 17.9 points (p=0.038). Patients with low or moderate irritability did not display statistically or clinically significant differences in patient improvement between fidelity classifications
CONCLUSIONS: The results of this study demonstrate preliminary evidence that adherence to guideline care may be most important in patients with high irritability. Guideline adherence in these patients is associated with better clinical outcomes and may prevent conversion to more costly chronic conditions. Future study is warranted to evaluate this approach
CLINICAL RELEVANCE: Subject to further investigation, adherence to guideline based care may be most important in patients with high irritability. This may have implications for allocation of time and resources clinically and in future therapeutic analyses